APPLICANT INFORMATION - Virginia

ANTIQUE and VINTAGE

Virginia Department of Motor Vehicles Post Office Box 27412 Richmond, Virginia 23269-0001

LICENSE PLATE CERTIFICATION

(( ) -

dmv.

Purpose:

Owners of antique motor vehicles, trailers, motorcycles and autocycles use this form to certify complia(n(ce) wit-h Code of Virginia

requirements for use of antique and vintage plates.

Instructions: Return the completed VSA 10 B form (along with a VSA 10, VSA 14 or VSA 17A) with the one-time nonrefundable, nontransferable $50

fee and any other applicable fees to any DMV customer service center. You may also mail the forms and fees to DMV, Special Plates,

P.O. Box 26668, Richmond, VA 23261-6668. Fees for General Use Vintage Plates are the same as standard vehicle registration fees.

OWNER FULL NAME (last, first, middle initial) (print)

APPLICANT INFORMATION

OWNER TELEPHONE NUMBER

CO-OWNER FULL NAME (last, first, middle initial) (print)

CO-OWNER TELEPHONE NUMBER

STREET ADDRESS

CITY

STATE

ZIPCODE

SELECT ONE LICENSE PLATE TYPE:

Antique Plate (Black and White)

Antique - Yellow (Yellow with Blue

Lettering)

Vintage Plate (Antique Use Only)

YEAR

Vintage Plate - General (Daily) Use

(Requires displaying month and year decals on the license plate, annual renewal fees and safety inspection.)

YEAR

USE OF ANOTHER VEHICLE, MOTORCYCLE OR AUTOCYCLE

Virginia Code, Section 46.2-730, requires evidence that the applicant named above owns or has regular use of another passenger car, motorcycle or autocycle. Antique plates will not be issued and vintage plates will not be approved without this certification. The vehicle must have active registration. If the registration is inactive or the information is incorrect, the certification will not process.

I certify that I own at least one other properly registered vehicle, motorcycle or autocycle. (Describe below)

VEHICLE TITLE NUMBER

VEHICLE IDENTIFICATION NUMBER (VIN)

MAKE

MODEL

LICENSE PLATE NUMBER

I do not own another properly registered vehicle, motorcycle or autocycle; however, I certify that I have regular use of at least one other properly registered vehicle, motorcycle or autocycle as authorized by the owner/co-owner below.

VEHICLE TITLE NUMBER

STATE OF TITLE VEHICLE IDENTIFICATION NUMBER (VIN)

MAKE

MODEL

LICENSE PLATE NUMBER

OWNER FULL NAME (last, first, middle initial) (print)

OWNER SIGNATURE

CO-OWNER FULL NAME (last, first, middle initial) (print)

CO-OWNER SIGNATURE

INSURANCE CERTIFICATION

I/We certify that this vehicle is insured by a liability policy issued through an insurance company NAME OF INSURANCE COMPANY licensed to do business in Virginia and it will remain insured while registered, whether or not it is operated. Penalties are severe for violation of this requirement.

USE OF ANTIQUE OR VINTAGE ANTIQUE USE ONLY PLATES

Virginia Code, Section 46.2-730, limits use of antique vehicles, trailers, motorcycles and autocycles registered with antique or vintage plates to the participation in club activities, exhibits, tours, parades and similar events and to carrying or transporting passengers, personal effects and other antique vehicles for show purposes. They may also be used on Virginia highways to test vehicle/trailer operation, obtaining maintenance or repairs and/or to sell the vehicle or trailer. Antique and vintage plates permit occasional pleasure driving (not to exceed 250 miles from the owner's residence) but are not to be used for general transportation purposes, including but not limited to, daily travel to and from the owner's place of employment.

PENALTY FOR MISUSE OF ANTIQUE OR VINTAGE ANTIQUE USE ONLY LICENSE PLATES

Any owner of an antique vehicle, trailer, motorcycle or autocycle registered with license plates pursuant to Virginia Code, Section 46.2-730, will be guilty of a Class 4 misdemeanor if convicted of a violation of antique or vintage plate usage. The conviction will cause the owner's registration for the vehicle involved in the violation to be revoked for a five-year period from the date of conviction.

ANTIQUE VEHICLE SAFETY CERTIFICATION

Virginia Code, Section 46.2-730, requires that you certify that the antique vehicle, trailer, motorcycle or autocycle registered with antique or vintage plates is capable of being safely operated on Virginia highways.

VEHICLE TITLE NUMBER

VEHICLE IDENTIFICATION NUMBER (VIN)

MAKE

MODEL

LICENSE PLATE NUMBER

I/We certify and affirm that all information presented in this form is true and correct, that any documents I/we have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I/We make this certification and affirmation under penalty of perjury and I/we understand that knowingly making a false statement or representation on this form is a criminal violation.

OWNER SIGNATURE

DATE (mm/dd/yyyy) CO-OWNER SIGNATURE

DATE (mm/dd/yyyy)

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